Medicare Compliance & Reimbursement

Physician presence rules in the teaching hospital setting are among the oldest compliance hot buttons around, but the feds haven't let up on investigating claims that sometimes go back a decade or more.

Billing rules for care provided in academic medical centers were at the heart of the notorious Physicians at Teaching Hospitals initiative, in which hospitals across the country coughed up millions of dollars - indeed, sometimes tens of millions -in high-profile settlements. Those investigations involved the complicated billing rules that apply to teaching physicians and residents, and the extent to which faculty docs need to be physically present to bill for care.

Similar issues arose in a recent settlement between the Department of Justice and a Philadelphia orthopedic surgeon - with a key difference: The doctor only had to pay single damages plus interest to resolve the case, not the astronomical fines the feds sometimes pursue. According to U.S. Attorney Patrick Meehan, Dr. Richard Roth-man and his billing company, Reconstructive Orthopaedic Associates II, will pay just over $838,000, plus interest, to settle charges that he billed as the attending surgeon for procedures when he wasn't in the operating room long enough to satisfy Medicare reimbursement rules.

Rothman countered that he "provided all of the services expected of a physician both as a matter of proper medical care and as required by all regulations relating to reimbursement," according to settlement documents. The claims at issue in the case dated back to 1993-1996.

As part of the settlement, Rothman will enter into a five-year integrity agreement, which includes periodic review by an independent audit firm.

Lesson Learned: Don't assume old-school fraud and abuse targets have faded from the feds' radar screen just because they've dropped off the headlines.